Claim for Expenses Incurred and Paid
Reimbursement Program for Living Donors (RPLD)
This form must be completed by the applicat in block letters.
Family name of applicant :
Given name of applicant :
-
Date of birth of applicant:
yyyy
mm
dd
Health insurance number :
The applicant lives :
60 kilometers or less from the transplant centre
60 to 100 kilometers from the transplant centre
100 kilometers or more from the transplant centre
Travel/transportation by car
Travel expenses related to transportation by car may be claimed only if the applicant lives 60 kilometers or more from the transplant
centre.
Date of the visit
(yyyy-mm-dd)
Reason for
the visit *
*Reasons for the visits are :
Page 1 of 4
Mileage
$0.43 / KM
Amount claimed
Reserved for Transplant Québec
E = Examination
S = Stay
S = Surgery
RPLD03 - December 2011
Travel by other means of transportation
Travel expenses incurred via other means of transportation may be claimed only if the applicant lives 100 kilometers or more from
the transplant centre. An invoice or receipt must be included to justify each amount claimed.
Date of the visit
(yyyy-mm-dd)
Reason for
the visit *
*Reasons for the visits are :
Means of transportation
used
Amount claimed
Reserved for Transplant Québec
E = Examination
S = Stay
S = Surgery
Sub-total for travel expenses:
* Up to a maximum of $ 1,500
Parking
Parking expenses may be claimed regardless of the distance between the applicant's home and the transplant centre.
A receipt must be included to justify each amount claimed.
Date of the visit
(yyyy-mm-dd)
Reason for
the visit *
*Reasons for the visits are :
Reserved for Transplant Québec
E = Examination
S = Stay
S = Surgery
Sub-total for parking expenses:
Page 2 of 4
Amount claimed
* Up to a maximum of $140, daily maximum $20
RPLD03 - December 2011
Accommodation
Accommodation expenses may be claimed only if the applicant lives 100 kilometers or more from the transplant centre.
An invoice must be included to justify each amount claimed.
Date of the visit
(yyyy-mm-dd)
Reason for
the visit *
*Reasons for the visits are :
Amount claimed
Reserved for Québec-Transplant
E = Examination
S = Stay
S = Surgery
Sub-total for accommodation expenses :
* Up to a maximum of $650, daily maximum $130
Meals
Meals expenses may be claimed only if the applicant lives 100 kilometers or more from the transplant centre.
An invoice must be included to justify each amount claimed.
Date of the visit
(yyyy-mm-dd)
Reason for
the visit *
*Reasons for the visits are :
Reserved for Transplant Québec
E = Examination
S = Stay
S = Surgery
Sub-total for meals expenses :
Page 3 of 4
Amount claimed
* Up to $225, daily maximum $45
RPLD03 - December 2011
Total amount claimed
Expenses
Amount claimed
Reserved for Transplant Québec
Sub-total for travel expenses:
Sub-total for parking expenses :
Sub-total for accommodation expenses :
Sub-total for meals :
Total :
I hereby certify that the information provided on this form is accurate and complete.
(Signature of applicant)
Page 4 of 4
yyyy
mm
dd
RPLD03 - December 2011